Short Form A (SFN8317) "Application for Permit to Discharge (Ndpdes) - Domestic" - North Dakota

What Is Short Form A (SFN8317)?

This is a legal form that was released by the North Dakota Department of Environmental Quality - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2021;
  • The latest edition provided by the North Dakota Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Short Form A (SFN8317) by clicking the link below or browse more documents and templates provided by the North Dakota Department of Environmental Quality.

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Download Short Form A (SFN8317) "Application for Permit to Discharge (Ndpdes) - Domestic" - North Dakota

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FOR DEPT. USE ONLY
APPLICATION FOR PERMIT TO DISCHARGE
Application No.
(NDPDES) DOMESTIC – SHORT FORM A
NORTH DAKOTA DEPARTMENT OF ENVIRONMENTAL QUALITY
Date Received
DIVISION OF WATER QUALITY
SFN 8317 (08/21)
GENERAL INFORMATION
Legal name of organization responsible for facility
Phone no.
Mailing address
City
State/Province
Zip code
Name of facility
Contact person name
Contact phone no.
Contact mailing address
City
State/Province
Zip code
Average population served
Location of treatment system:
County
¼
¼
SEC.
TWP.
RGE.
Does the facility receive any industrial waste?
NO
YES
Approximate number of industrial dischargers into system:
Check any facility in the service area of your treatment plant:
Beverage manufacturing
Electroplating
Metal finishing
Restaurants
Centralized waste treatment
Hospitals, medical clinics, dentists
Metal molding & casting (foundry)
Transportation equipment cleaning
Concrete ready-mix
Leather tanning & finishing
Oil & gas extraction
Other (describe):
Dairy products
Meat products & processing
Petroleum refining
Estimated percentage of influent flow that is domestic:
Estimated percentage of influent flow that is industrial:
Does the treatment system receive any
Does the facility have a monitoring
NO
YES
NO
YES
hauled-in wastes, including septage haulers?
plan for accepting hauled waste?
If yes, describe the kinds of waste received and if any such waste is
Describe:
subject to local or federal regulations:
Does the facility have a dedicated
NO
YES
hauled waste discharge location?
If no, where is hauled waste discharged into the facility?
How many days per month is septage dumped?
How many septic companies dump septage?
TYPE OF TREATMENT
(complete either A or B below):
A. SEWAGE LAGOON
B. MECHANICAL WASTEWATER TREATMENT PLANT
CELL NUMBER
CELL SIZE
Provide a brief narrative of the treatment process, including sludge handling:
IN ACRES
EFFLUENT CHARACTERISTICS
Design flow rate (1000s gal/day):
TSS (mg/L):
E. Coli (CFU/100 mL):
BOD
(mg/L):
NH
-N (mg/L):
5
3
Check any of the following contained in the discharge:
Aluminum
Cadmium
Copper
Lead
Nickel
Selenium
Beryllium
Chromium
Cyanide
Mercury
Phenols
Zinc
Name of laboratory or consulting firm conducting the analysis
Phone No.
Mailing address
City
State/Province
Zip code
Name of laboratory or consulting firm conducting the analysis (if more than one)
Phone No.
Mailing address
City
State/Province
Zip code
FOR DEPT. USE ONLY
APPLICATION FOR PERMIT TO DISCHARGE
Application No.
(NDPDES) DOMESTIC – SHORT FORM A
NORTH DAKOTA DEPARTMENT OF ENVIRONMENTAL QUALITY
Date Received
DIVISION OF WATER QUALITY
SFN 8317 (08/21)
GENERAL INFORMATION
Legal name of organization responsible for facility
Phone no.
Mailing address
City
State/Province
Zip code
Name of facility
Contact person name
Contact phone no.
Contact mailing address
City
State/Province
Zip code
Average population served
Location of treatment system:
County
¼
¼
SEC.
TWP.
RGE.
Does the facility receive any industrial waste?
NO
YES
Approximate number of industrial dischargers into system:
Check any facility in the service area of your treatment plant:
Beverage manufacturing
Electroplating
Metal finishing
Restaurants
Centralized waste treatment
Hospitals, medical clinics, dentists
Metal molding & casting (foundry)
Transportation equipment cleaning
Concrete ready-mix
Leather tanning & finishing
Oil & gas extraction
Other (describe):
Dairy products
Meat products & processing
Petroleum refining
Estimated percentage of influent flow that is domestic:
Estimated percentage of influent flow that is industrial:
Does the treatment system receive any
Does the facility have a monitoring
NO
YES
NO
YES
hauled-in wastes, including septage haulers?
plan for accepting hauled waste?
If yes, describe the kinds of waste received and if any such waste is
Describe:
subject to local or federal regulations:
Does the facility have a dedicated
NO
YES
hauled waste discharge location?
If no, where is hauled waste discharged into the facility?
How many days per month is septage dumped?
How many septic companies dump septage?
TYPE OF TREATMENT
(complete either A or B below):
A. SEWAGE LAGOON
B. MECHANICAL WASTEWATER TREATMENT PLANT
CELL NUMBER
CELL SIZE
Provide a brief narrative of the treatment process, including sludge handling:
IN ACRES
EFFLUENT CHARACTERISTICS
Design flow rate (1000s gal/day):
TSS (mg/L):
E. Coli (CFU/100 mL):
BOD
(mg/L):
NH
-N (mg/L):
5
3
Check any of the following contained in the discharge:
Aluminum
Cadmium
Copper
Lead
Nickel
Selenium
Beryllium
Chromium
Cyanide
Mercury
Phenols
Zinc
Name of laboratory or consulting firm conducting the analysis
Phone No.
Mailing address
City
State/Province
Zip code
Name of laboratory or consulting firm conducting the analysis (if more than one)
Phone No.
Mailing address
City
State/Province
Zip code
DISCHARGE POINT LOCATION
(Complete either Latitude and Longitude OR Section, Township, and Range):
Point ID
County
Latitude
Longitude
¼
¼
SEC.
TWP.
RGE.
Point ID
County
Latitude
Longitude
¼
¼
SEC.
TWP.
RGE.
Point ID
County
Latitude
Longitude
¼
¼
SEC.
TWP.
RGE.
Receiving stream: Provide a brief description of area to which treated discharge flows (i.e. river, unnamed stream, landlocked slough, lake, etc.). Use
names whenever possible.
SIGNATURE
I certify under penalty of law that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and
RETURN COMPLETED
evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
APPLICATION TO:
those persons directly responsible for gathering the information, the information submitted is, to the best of my
knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for
North Dakota Dept. of Env. Quality
submitting false information, including the possibility of fine and imprisonment for knowing violations.
Division of Water Quality
4201 Normandy Street
Printed name of applicant(s)
Title
Bismarck, ND 58503-1324
Signature of applicants(s)
Date
Telephone:
(701) 328-5210
Fax:
(701) 328-5200
(Attach additional pages if needed)
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